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2. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.

3. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...

4. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes ( SOAP ...

5. Daily production report - Wikipedia

   en.wikipedia.org/wiki/Daily_production_report

   Daily production report. A daily production report ( DPR) or production report (PR) in filmmaking is the form filled out each day of production for a movie or television show to summarize what occurred that day. There is no standard template for a production report and each show usually has an original template, often created before production ...

6. Case report form - Wikipedia

   en.wikipedia.org/wiki/Case_report_form

   A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF ...

7. Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Clinical_Document_Architecture

   The HL7 Clinical Document Architecture ( CDA) is an XML -based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition".

8. Change-of-shift report - Wikipedia

   en.wikipedia.org/wiki/Change-of-shift_report

   In healthcare, a change-of-shift report is a meeting between healthcare providers at the change of shift in which vital information about and responsibility for the patient is provided from the off-going provider to the on-coming provider (Groves, Manges, Scott-Cawiezell, 2016). [1] Other names for change-of-shift report include handoff, shift ...

9. Continuity of Care Document - Wikipedia

   en.wikipedia.org/wiki/Continuity_of_Care_Document

   These documents must be capable of including data elements known as the "Common MU Data Set" that include: Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions ...